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DECLARATION FOR WINTER TIRE DISCOUNT
Spoke to Broker
Basic Information
First Name:
Last Name:
Binder Number:
Clinet Email:
Address
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Consent
Winter tires installed Dec–March
Information is correct
AUTO DECLINE COVERAGE DECLARATION
Business Exposure:
Yes
No
Optional AB:
Yes
No
Liability:
Yes
Declined
Collision:
Yes
Declined
Comprehensive:
Yes
Declined
OEF 43:
Yes
Declined
Accident Protector:
Yes
Declined
Loss of Use:
Yes
Declined
Telematics / App Details
0
1
2
3
4
5
Uber / Food Delivery:
Yes
No
Generate